Ophthalmology

Acquired ptosis can be divided into neurogenic, myogenic, traumatic, mechanical and aponeurotic. The mechanism for myasthenia gravis consists of antibodies to acetylcholine receptors at the nicotinic neuromuscular end terminus of the neuromuscular junction. These antibodies block acetylcholine interaction with its receptors on the neuromuscular end plate, leading to weakness. The most common complaints from patients include diplopia and ptosis, frequently at the end of the day. With that said, it can be much more subtle and problematic. Let me give you some examples.

It has always been the teaching that recurrent unilateral conjunctivitis must be evaluated for partial or complete nasal lacrimal duct obstruction. This may be congenital or acquired. In the adult population, women are more commonly involved than men, with an average age range of 50 to 70 years. This may be caused by a narrower nasal lacrimal duct system than in men or postmenopausal hormonal changes on the mucosa. The diagnosis is made by observing discharge or epiphora, pressing on the lacrimal sac fossa to see if the lacrimal sac is enlarged or painful. If discharge on pressure emanates from either punctum, the diagnosis is made of nasal lacrimal duct obstruction, with the blockage distal to the lacrimal sac. Otherwise, it is necessary to gently irrigate the lacrimal system, looking for reflux from the lower system to the upper system, with little to no irrigant going down the nasal lacrimal duct. A DCR is highly successful in resolving the problem.

I have always been interested in sarcoidosis in the way it presents and its diagnostic dilemma, so I would like to pose three test questions and follow up with a discussion to build upon the questions.

It is always a pleasure to attend our national meeting and have the opportunity to see old friends and reassess one's educational experience. The subspecialty day is most valuable, as it discusses controversial topics and allows the physician to be challenged from his or her past experience with what is the new thinking on the subject. The interactive response is very interesting, especially when the speaker presents his or her thoughts about the best way to manage a problem, and surprisingly almost half the audience disagrees and is not planning on incorporating it into their practice. 

Interestingly, I have been referred patients with subconjunctival fat prolapse with the referring physician somewhat unsure of what the entity is and what the treatment options are.

Too often in practice, patients with a chalazion come back to the ophthalmologist multiple times after treatment with warm compresses, massage, topical antibiotics, systemic antibiotics (tetracycline) and steroid injections (triamcinolone acetate 2 mg). Attempts at incision and drainage may be suboptimal, leading to a frustrated patient after three or four visits.

The first papers I was a co-author on were in collaboration with dermatology regarding blistering diseases of the conjunctiva and mucus membranes. This became known as cicatricial pemphigoid as opposed to benign mucus membrane pemphigoid, which is far from a benign disease. At the time, biopsy specimens were transported to the lab with dry ice, which was soon replaced with Michel’s fixative (a great friend). Below is an overview of a disease process that is important to recognize and treat.

Trichiasis refers to abnormal lash growth with the lashes directed posteriorly toward the globe. Unlike entropion, the eyelid is at a normal position.

The pathogenesis of trichiasis involves the creation of micro-cicatrices in the area of the eyelash follicles with lash distortion and misdirection. The process may cause keratinization of the lid margin mucosa, which causes ocular surface problems. The ultimate results of trichiasis lead to pain, corneal scarring and decreased vision.

There are three types of orbital implants in enucleation surgery. 1. Buried nonintegrated, in which a spherical implant is placed through a rent and posterior Tenon’s capsule into the muscle cone. 2. Quasi-integrated (Iowa implant), in which the muscles are placed between implant mounts that then, after closure, interdigitate with depressions in the prosthesis. 3. Exposed integrated, in which part of the orbital plant is buried and part is externally exposed and directly connected to a pro...

When I was a resident, enucleation and evisceration were first-year resident procedures. I was surprised at the choice because of the traumatic decision that a patient had to make regarding loss of a body part. The patient surely hoped that the removal of a blind painful eye or one that may harbor a tumor would be successfully performed with an anticipated good cosmetic result. In enucleation surgery, the goal was harder to achieve than in evisceration surgery because invariably the spherical im...